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Thyrotoxic Storm Following Thyroidectomy Follow-up

  • Author: Peter F Czako, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jan 21, 2015
 

Further Inpatient Care

Combined use of propylthiouracil, iodine, and dexamethasone has an effect within 24-48 hours, and the serum levels of T3 and T4 return to normal. Clinical signs of decreasing pulse, normal temperature, and improved mental status mark effective management. Complete recovery takes 10-12 days. Dexamethasone can be tapered thereafter.

The three modalities of definitive management are radioiodine, antithyroid drugs, and surgery.[9]

Prior to radioiodine therapy or surgery, a patient should be made euthyroid with antithyroid drugs and propranolol. Antithyroid drugs are administered for 12-24 months, during which, a remission may occur. Antithyroid drugs are continued until a normal metabolic state is reached. If in remission, the patient should be closely monitored for 6 months, as relapse is more common during this period after discontinuation of therapy. Iodine is progressively withdrawn. Serially monitor patients until the thyroid gland is sufficiently depleted of its hormone to allow radioiodine therapy. Delaying radioiodine ablation for several months may be necessary because of the large doses of iodine used in management of thyroid storm. Some surgeons may reintroduce iodine for 10 days prior to surgery if subtotal thyroidectomy is planned. Follow patients for up to 5 years.

Criteria established by Burch and Wartofsky help in early recognition of impending storm. In thyroid storm, management as described improves the chance of survival.[4]

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Deterrence/Prevention

Identification of precipitating factors

  • Surgery and anesthesia induction, labor, thioamide withdrawal, and use of radioiodine are known precipitants of thyroid storm. However, these precipitants may not be discovered frequently.
  • Precipitating factors are not found in all patients, but a meticulous search improves chances for a successful outcome.
  • Chest radiographs and blood, urine, and sputum cultures may be needed to identify intercurrent illness (eg, infection).
  • Judicious use of empiric antibiotics is needed if no obvious source is found.

Prevention of recurrence

  • Prevention of a recurrent crisis should be the main objective until completion of definitive therapy.
  • Vigilant monitoring of signs and symptoms of hyperthyroidism during preoperative or pre-anesthetic evaluation is paramount.
  • Consider precipitating factors when deciding on treatment modalities.
  • Adequate control of the thyrotoxic state prior to initiation of definitive therapy is important. Carry out procedures only after the patient is euthyroid.
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Patient Education

For excellent patient education resources, visit eMedicineHealth's Thyroid and Metabolism Center. Also, see eMedicineHealth's patient education articles Thyroid Problems and Thyroid Storm.

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Contributor Information and Disclosures
Author

Peter F Czako, MD, FACS Chief, Division of Endocrine Surgery, Medical Director, North Tower Operating Rooms, Surgical Administration, William Beaumont Hospital; Associate Professor, Department of Surgery, Oakland University William Beaumont School of Medicine; Royal Oak Surgical Associates, PC

Peter F Czako, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Michigan State Medical Society, American Association of Endocrine Surgeons, Detroit Surgical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nafisa K Kuwajerwala, MD Staff Surgeon, Breast Care Center, William Beaumont Hospital

Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Breast Disease

Disclosure: Nothing to disclose.

Gunateet Goswami, MD Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital

Gunateet Goswami, MD is a member of the following medical societies: American Medical Association, American Society of Echocardiography, Michigan State Medical Society

Disclosure: Nothing to disclose.

Thabet Abbarah, MD, FACS Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers

Thabet Abbarah, MD, FACS is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Pankaj Chaturvedi, MBBS, MS, FACS Professor of Head and Neck Surgery, Department of Head and Neck Surgery, Tata Memorial Hospital, India

Pankaj Chaturvedi, MBBS, MS, FACS is a member of the following medical societies: American Association for the Advancement of Science, American Head and Neck Society, Association of Surgeons of India

Disclosure: Nothing to disclose.

Venkata Subramanian Kanthimathinathan, MD Fellow in Bariatric/Advanced Laparoscopic Surgery, University of Missouri Healthcare

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dean Toriumi, MD Associate Professor, Department of Otolaryngology, University of Illinois Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Mimi S Kokoska, MD Physician, Department of Otolaryngology-Head and Neck Surgery, Aurora Health Care

Mimi S Kokoska, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American College of Surgeons, American Head and Neck Society

Disclosure: Nothing to disclose.

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Pathophysiologic mechanisms of Graves disease relating thyroid-stimulating immunoglobulins to hyperthyroidism and ophthalmopathy. T4 is levothyroxine. T3 is triiodothyronine.
Table. Symptoms and Signs of Thyroid Storm When Compared with Uncomplicated Thyrotoxicosis
Uncomplicated Thyrotoxicosis Thyroid Storm
1. Heat intolerance, diaphoresis 1. Hyperpyrexia, temperature in excess of 106o C, dehydration
2. Sinus tachycardia, heart rate 100-140 2. Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure
3. Diarrhea, increased appetite with loss of weight 3. Nausea, vomiting, severe diarrhea, abdominal pain, hepatocellular dysfunction-jaundice
4. Anxiety, restlessness 4. Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma
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